A short version might be, “Just when you think you are making progress, you don’t understand how you are undercutting your own efforts. Keep trying and learning. This quality stuff isn’t easy.”

Read it and let Jim know what you think. Excerpts:

The CMO of a rural community healthcare system was pleased after kicking off a patient safety meeting with more than 100 front-line clinical, administrative and support staff. The organization had shown a dramatic decline in serious adverse events and now the numbers for most months were very small. The chart showing the downward trend was striking. He was therefore stunned with the first comment from staff: “If that’s what you think then it is clear you don’t have any idea of what goes on in my unit every day.”

This story is real. It occurred in an excellent organization, and I was there as it unfolded. The organization’s leaders knew that if you try to do everything, you will accomplish nothing, so they set strategic quality and safety targets and the organization was on an active journey forward. However, they became too focused on these few events, forgetting that their targets were a small piece of the universe of harm and failure, maybe just 5% of it. No mention was made at the meeting of the larger context of failure. No mention was made as to how this data linked to all the incident reports that get filed every day. For the front-line staff, what leadership was saying bore no resemblance to the failure they, patients and family members deal with every day.

On one occasion during my own career, a physician leader was presenting some strong work from a team on a new clinical information system. At the end of the presentation I congratulated the team and asked “What new categories of error are we implementing with this system?” With a very frustrated and abrupt tone the leader replied, “Aren’t you ever satisfied?” I thought and then said “No, I can’t be.”

Every time you change a system, what is your approach to critical risk assessment, to failure detection?

As a young leader I loved being a firefighter, coming in on a great big problem, and leading the team that fixed it. Then a colleague suggested that maybe those problems shouldn’t have risen to that stage if I and we had been doing a better job in the first place. If a strong system had been built, and we were listening to the signals suggesting problems, we could have fixed them earlier. Many clinical colleagues say they’ve seen a similar scenario, often at morbidity and mortality conferences. The focus is on the save and not on the fact that the harm shouldn’t have happened in the first place.

Organizations and their leaders must develop this pre-occupation with failure and then do something with the data.

Dr. Seuss has taught us “the more that your learn, the more places you will go.” John Kelsch of Xerox noted “To do things differently, we must see things differently. When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before.” Each of us has seen and been part of exceptional care and caring. A pre-occupation with failure will help us move closer to that being the experience of EVERY patient, family member, and staff member, EVERY time.